REMY diagnosed last week

[Remy’s Mom]

UPDATE REMY: Finally got the ACTH Stem tests back on Remy and his adrenal has recovered and he is back within normal range. (135 and 129) So they are recommending we resume trilostane this morning at 5mg once a day since that is the lowest available dose without compounding. We will recheck in a few weeks to see how he is responding. They also recommended changing his insulin but the past couple of days I’ve had some luck by giving his insulin around 300 even if it’s a little early. He always spikes after eating so my thinking is why must we let him get uncomfortably high just so he can eat and have his insulin at exactly 12 hours? Also, I don’t want to change too much at the same time. I would rather take steps as far as introducing different medications or treatments so we know exactly what is affecting. Anyone with experience with Diabetic pets or Cushings/Diabetic pets please reach out to me because I would sure love to pick your brains!! The K9 Diabetes forum doesn’t seem to be active anymore. Meanwhile, thank you all so much for your thoughts on Remy’s situation. You are wonderful and provide so much help and support!! I will continue to update as we see how he does on his new dose!!

[Harley PoMMom]

As you know I'm new to this diabetic thing myself, but the vet told me that the one important part is feeding my cat a low carb wet cat food, and I see for myself that this does play an important part in blood sugar numbers. I don't always inject at exactly 12 hours, usually within 1/2 hour of next scheduled shot, so for me and cat it's 6-6:30 am and 6-6:30 pm. He's usually high at the beginning and slowly declines around 2-3 hours after insulin shot.

[Remy’s Mom]

We try use a low carb wet dog food. He won’t eat the same thing ( for breakfast and dinner the same day) so Remy is very picky. We spoon feed him It’s a lengthy process sometimes but it works. He’s done when we finish the bowl. Otherwise he would graze or be inconsistent in his eating. I use the same brand and type food which we found agrees with him and to maintain consistency. Still, he’s all over the place with his glucose. We do 10 am and 10 pm since he’s a very late riser. He also has almost immediate post prandial spikes as soon as he starts eating so I’m experimenting with not letting him get up quite so high before giving the insulin. It’s definitely complicated and has pretty much taken over my life. If this doesn’t do the trick I’m game to try a new insulin but I’ll want to do it when I’m home all week so I won’t have to worry about any hypoglycemic episodes if I’m gone. Thank goodness for the continuous glucose monitor!!

[Harley PoMMom]

What type of insulin are you using? In the beginning we used Lantus but that seemed to drop him too low, so we've switched to Prozinc which is working better.

[Remy’s Mom]

For the most part Remy has been on Vetsulin. The problem is it takes too long to take effect and doesn’t last long enough. We tried PZI (prozinc) but didn’t have much luck with it either so went back to Vetsulin. They want me to try Degludec which I believe is similar to Lantas. My concern would be the risk of hypoglycemia. I don’t think we should make a change until Remy has been back on the trilostane for a bit to make sure he has adjusted, cortisol levels are normal etc. Then we can see about a change in insulin. Right now I am experimenting with giving him the Vetsulin a little earlier instead of adhering to a rigid every 12 hour schedule. If he’s within a couple of hours of that and his glucose is over 300 I will go ahead and feed him and give him his insulin. On average it takes 4 hours to kick in. When he eats his glucose spikes so maybe this will help his glucose from going to the moon.I figure it’s worth trying while he acclimates to his new dose of trilostane. I don’t like to change too many things at once in case he has some negative reaction.

[Remy’s Mom]

A little update on Remy. Had a snap cortisol a couple of weeks ago and he was at 2.6u (mid 70s on nmol scale) which isn’t bad but I do not want him to fall too low again. Since 5mg is the lowest dose of Vetoryl without compounding his primary care and I decided to try 5 mg trilostane every other day and see where we get. We will do an ACTH next week and get more precise results. (I had to switch from evening to morning dosing). Once we get this resolved I will work on the diabetes situation. K9 Diabetes forum no longer seems to be active. There are new approaches with hard to regulate diabetic dogs using a BBIT (basal / bollus insulin therapy)protocol but most veterinarians seem reluctant to try it even though it has been used in humans for many years due to the risk of hypoglycemia. As always any comments and suggestions are greatly appreciated!

[Squirt's Mom]

I can't help with the diabetes but I do have a concern with the resumption of treatment with a normal cortisol reading...and dosing schedule.

Vetoryl is used to lower cortisol when it is elevated. It is not used to maintain a normal reading after a dog has dropped too low. The protocol says to wait until the dog is showing strong signs again AND has an ACTH showing the cortisol is once again HIGH...not normal, and then restart at a lower dose than previous. So the risk of dropping too low again is higher by restarting with a normal cortisol reading. I am basing this on the 2.6u reading as 2.6ug/dl which isn't too low but you don't want it going lower, as you said.

Now, Vetoryl/Trilostane has a VERY short life in the body (2-12 hours) so dosing every other day 1) puts the dog on a sort of cortisol roller coaster which is not good for the adrenal glands, 2) offers little to no control of the cortisol, and 3) is a complete waste of your money. The beauty of compounding medicine is that you can get an exact dose. The liquid Trilostane is especially nice because often you can adjust the dose without having to buy a new prescription...simply increase or decrease as needed per the vet. FYI...Trilostane is compounded Vetoryl.

If the vet is running the ACTH vs the PVC test to monitor treatment then dosing at night won't work due to the strict testing schedule for the ACTH. The PVC had a bit more leeway.

Hope I haven't confused you more.
Leslie

[Remy’s Mom]

Hi Leslie, Thank you so much for your thoughts. We are taking Remy this afternoon to recheck his cortisol level. Internist had us switch him back to morning dosing (still every other day) to better faciliate an accurate test. Have not heard of liquid Trilostane so I assume this is compounded. I don’t know why the vets seems so adverse to compounding but they aren’t recommending it. (I have used compounded medications in the past successfully). I was told to resume Vetoryl at 5 mg once a day after he retested at 135/129.That was after a couple of weeks off trilostane. Primary care did a snap cortisol (not an ACTH Stim) and he was 2.6 and that was on trilostane once a day. I was concerned he was headed back to a too low situation and we talked about trying it every other day. Internist mentioned some dogs are very sensitive and only take it a couple of times a week. I see your point though that given the short life of 2-12 hours doing an every other day doesn’t really achieve stability. Remy never had much in the way of Cushings symptoms. They were very mild (like he stopped being such a picky eater and was showing more interest in food like a normal dog) a little panting at night time. No increased urination or water consumption. Hair coat a little thinner but he lives in a hot climate and thyroid is at the lower end of the scale. Still, he doesn’t have bare patches and most people would say he has a lovely coat. no pot belly. So maybe we should keep him off trilostane and retest say in a month or two depending upon symptoms?? My problem is cortisol affects his diabetes which is not controlled and I’m about to lose my mind with it. I guess we see what it is this time and I will discuss what you’ve told me and see where we’re at I’m also keeping in mind just the stress of going to the vet is going to bump up the cortisol. I don’t see why the liquid trilostane would be a problem if he needs it at all. Thanks so much for your suggestions and I will ask and see what he says. I really appreciate it!!

[Remy’s Mom]

Hi Leslie,
Got the report back on Remy’s last ACTH test. Baseline was 29.2 nmol/L and post 34.8 nmol/L so his cortisol is low again and obviously 5 mg. Trilostane every other day is too much for him. My opinion, he shouldn’t be on any trilostane until his cortisol is actually high. They put him back on trilostane at 135 and 129 which is still within normal range back in January. We have discontinued trilostane for the moment. If he shows symptoms or tests ‘high’ I am going to push for a compounded liquid Trilostane because as you said, it is much easier to adjust the dose. With a 5 mg capsule I can’t adjust it. Prior to the test we did switch him back to Vetoryl in the morning with breakfast to faciliate a more accurate test. For whatever reason his internists aren’t crazy about using compounded medications but I have done so for many years with other drugs and didn’t have a problem. So his Internist is trying to connect with the Endocrinologist to see what they come up with. Between this and the irregular glucose I may just lose my mind LOL!

[Squirt's Mom]

I agree with you 1000% - he should not be on treatment at this time. You are doing a great job with a difficult situation so keep up the good work!
Hugs,
Leslie